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HomeMy WebLinkAbout79-00369 I, .. , ,', I, " " 'I '".J, " .., , , ,'" I, ., ,I< 'I 'm l " . I,. , , I " " , ,-':1,> i ,'" ",'I . '.. I , " ", . - ',~ ": I':l -'I- I ,. i. '~ " ..,I,' I' " 'I' .. .;J; , '8 " ,~ J', " =- ). 1'1 , " , .. ,': I' ,I' " , ", " " , j. ". ,. '" , , " , '" fl, " J ,1. 1,_' " , ;, " " d,' " II. L '" )"- " "I'" 'fli, ',' {I'- " "~I " " " " " " " 'I' '" " " -d.' , ~ , I ~_ "~I: " I' " 'L' ", !' ,. , I, ..' .1-' " " " '.. --I' I-~ .. " '. " ':. l' ", j',< !,\' ; t:';. ,,r'j/e. " ,. ,,' J' .' '.'1 .f' IF " ':,,, , "" ,,'t , I. "',- " 'I" "\. ('.1'111 ;,"11",. " . ~ -, " '. I ( -~ " " " : j 1" ~ I . '!.' J' '" J, "",- !' _ I' - ,f; ~' .'i, ,',' " 'j. ,\ ',1; ,. 'I 'If' ,,' I' , ," " " " " \'IIIININ,,: II 1\ d"'~.II" <1111'111.111' 1111,\ "'I')' I,)' 1'.1101",'1,'1 ,,' jdll II tl~'ll 011'11, I Q.C.T 1 (3 I.9lB 1 [],. ".2 ') 2.~.? 7 l I -:':l ,,- Datc No, This Is 10 cortify that this is a trllc copy of the rccord which Is 011 filc ill the l'clIlI.ylvallla f)cpartment of Hcahh, ill accordancc with Act 66, I', L. 304, approved by the General Assembly, Junc 29, t 953, . 1,.,...-4 \bcJA~ Leollard Dachmall, M,D. Sccretary of Health Harrisburg, Pcnnsylvanla .I (Iuued free on mllit uy ltAtUI) "IM""V DlIT, NO. COMMONWf!Al.TH OF pI!NNaV\.VANIA D6'''~TMeNT opt HIlA\.TH VITALlTATIITlCI 01 /90 7 ' ;.11 CERTIFICATE OF DEATH 8TAT~ flt..E NO, r' N.ml of tlHI.ltd IPlnU L I f\tll' - It,o., Whit., BI.ck, Am.rlcan Innlln, ..'c., . ) Counly of death ~.. 1..1 blrthd.y IV,.,) S Clly, 60'0, or ~~. B . Y'. V (,I) II hOII" 01 OP/ER, Of J{), '(.. In. I. llldic:uln tJO^, lnpollllnl ('''<<Iedy) 0, S10le 11, County (."I"._.~;J,,/I,-..., .(..,1;.-,/ Klld oIIIU""0" or IHelull'", ;-,~' }"'; .!) ~;"1 ,~ :..1 ,;'",:J/';'~'/< I " .____ lOlfil"hil'. .....::::...0~J.,t.. cil)'o,boro. ';j' , r" ~... I 1 '01"11 dllC(I(UOrl QcIl'olly Hvo'~ II, ::; limil.t.rf r'lh.,'. n.m. (f'IIU) Molh.,.. m'ld." rl.m. If'lr,tl IMidoll1 ,') /, , (l.utl 1 / ) />~ /' '("" ~~r I (llll CIHlol ,I' C,.. .' HL C::'.;r," ..~'. Inlormllnl" l1.m. (TVp. ar Prlnll :':':'1 ') I.~ " (9tf'"1 ar flr-O Nn.1 I j' - (/) ,...;. ( /./ lC,(y 01 Tj'....nl 'j' , ) .../ .".' II iBulI1 I~ /: I.orltllll\ / iSt.hll /) , /.' (.,:.~'),/ \,' ,/(;""// ,/ 1911 /~" '.; '-. 'm..r\( IIno 'lnlll /,-)?;.;:l f ;.t":'.i . -,.---;~,.;/ //~~,t~-t".... >/ / /j', I~:(.I ;':J' /,/J;?;:;,~~,:/~._, /t ,~5',.>" 20n (:~~:>),,,,,,;i,,.f/'/.I /:',',;, / ,,''-:- t'/ FO-~-'EJ In ~ ,0 H! . u ~ ~~f ,. ".glltl"" SllIn.hlf. :I ?.... I" r.lA,,~ To the b.U ul my k nuwl.dg., dD~H' ace, ,d It the tlm., d.U, and""",,,::' i , I .nd du. 113 the e,ullhl U.l.d. j L '. / "'0) . ,: 0 01,,,,,,,,. \" 0 u r.CUCl.A.1 ',' h.'~ l~flflllUI y'\'\'\, . ~...L, - - 8 ~ .., n.le Sign'lll IMo,rD.y,y,,1 HOllI 01 ~ A.M. ! E -, Dulll C~- ... .,. "oC\'l-10 "c IUS: P,..., >:tJl' ~;; l N'I1I' .nd Addr"' 131 C"11f1.r Phy,Ic;I.n, M.dlell EiJ:'mlnll or COlOne,1 print or IYpol /..,... .....- "r On thl IlIUI, olu,min.llon ,ndlol Irwull'l'110n. Hl my opinion, dUlh 6l;(lUrrtd "1h. llmll, d'llI .nd pl.ce .nd dUfl 10 lh. ~....'e(.IIt'lfd H'Il"ll1u.r 231\ 1\1111 1,11(1 Otto 5lgn.rl (Mo I Hou' 01 DlI<llI, 23C .... PM 2JU ,. ,., Pit' I IAI Ou.1a, ar .. II conMq....nC. Ofl (" 'C.A-eJ'.l".'-i C' ,'11 P bn.( I!nl., only an. nUll p.' IIn. fOI (AI IOI.nd leI Vl~i("L.(r(t-1 ~r('tC:(e.L--\T Int.,....t'IMIWI.n on.. I ."d dlllh 4, ........ 14' ~. YS Irtlmlcll.lI UII''': 101 Du. ta, 0' .. . conMQUllnc. af! Ct., 1-<" III S' UQ'I t) S , 5 In-.,.....I tJ41WH" , on..t tnd dU'h '1 fa. 1.\ IM',....fl tMtw"" nn..t end dlllh tCI_ AulOllty [J Vol ., J "113 Will e", 'flltrr'd In Mlttl'f..1 l!umlne, or Cnron." 28, lJ '1'" (] No PArt II. Olh" Slgnlflunt Condition' ~ Cantllllon' eonllHwtlng In dllth hul nOI rtl.ted 10 LUlU glvlwln "4FI I '" ';;;'e,17cIA" ()\IS ("dr., wl'~10vl ~lVlec\('Cltl\1lT1 t 1~~u,ciJe,t.luf1l" Unclel. o.t. at inlurv IMo"O.y, Yr,1 Hou, I'll A.~, OUc,lbt haw InjUrV CJe{lIl'~1 or r nd, IlIyel" (.pllcllvl InJuly P,M 20B 29C I.e.o InIIHY 1 home. 11m, IIr'II1, 'II). Inl,\-,'I work 1 [J Yu 290 Latltlon iSt,." 01 AfTO No,1 iCitv, 013'0,131 Twp.l .." -I .1 Nfl )91' 2!Hi " " !S~. 8 ~ ro ~~ ~ g M ~I~ .~ II ~~ p. H r;-... as ~ ~ Vl lJ'... ~ E ..... ~~ ~ ~ ~ liS " a,',1"l r'\~ ~~ II ~ . ..... E:1~ 8~ ~ r ~ VI ~ ~...>1 , l~ I ! !S~ ~~. bi i! ,. .. '''1 es u , ~ffi . lSl '~ ~ ,~i ~~ ~II ,. ,. I. . ;,' ~_I.f ~. ',' f 4. ,", .' , , ;'" \- ' .v"-',.,,, " "J // I { {E", 1:/_.,'-" 1,< . .. ,. l r/ ~". ,,' (." . , " .